Antepartum Nursing (CH12)

Antepartum Nursing (CH12) Pregnancy Definitions:  Antepartum: Time between conception and onset of labor, usually used to describe the period during which a woman is pregnant; used interchangeably with prenatal.  Intrapartum: Time from onset of labor until the birth of the infant and placenta.  Postpartum: Time from birth until the woman’s body returns to an essentially prepregnant condition, typically about 6 weeks.  Gestation: The number of weeks since the first day of the last menstrual period (LMP).  Term: The American College of Obstetrics and Gynecology (ACOG) (2013a) recommends that the label term no longer be used. Instead, the following definitions are preferred: o Early term: Extending from 37 0/7 weeks through 38 6/7 weeks gestation (37-38) o Full term: Extending from 39 0/7 weeks through 40 6/7 weeks gestation (39-40) o Late term: Extending from 41 0/7 weeks through 41 6/7 weeks gestation (41) o Postterm: 42 0/7 weeks and beyond (42+)  Postterm labor: Labor that occurs after 42 weeks of gestation.  Preterm or premature labor: Labor that occurs > 20 weeks but < 37 weeks of gestation  Abortion: Birth that occurs before 20 weeks gestation or the birth of a fetus-newborn who weighs less than 500 g. An abortion (ab) may occur spontaneously or it may be induced by medical or surgical means. If induced, it is often termed a therapeutic abortion.  Gravida: Any pregnancy, regardless of duration, including present pregnancy. o Nulligravida: A woman who has never been pregnant. o Primigravida: A woman who is pregnant for the first time. o Multigravida: A woman who is in her second or any subsequent pregnancy.  Para: Birth after 20 weeks gestation, regardless of whether the infant is born alive or dead. o Nullipara: A woman who has not given birth at more than 20 weeks gestation. o Primipara: A woman who has had one birth at more than 20 weeks gestation, regardless of whether the infant is born alive or dead. o Multipara: A woman who has had two or more births at more than 20 weeks gestation. o Stillbirth: A fetus born dead after 20 weeks’ gestation.  TPAL: o T: number of term births the woman has experienced (number of birth* at the 37 0/7 weeks gestation or beyond) o P: number of preterm births (births* after 20 weeks but before 37 0/7 weeks gestation, whether living or stillborn) o A: number of pregnancies* ending before 20 weeks gestation, in either spontaneous or therapeutic abortion o L: number of currently living children to whom the woman has given birth o *Multiple gestation does NOT change the number of pregnancies/births  (ex. Twins would be T/L/A of 1, but L 2 if both living) MUST KNOW FOR TEST from CH 10:  Placenta gives oxygenation and nutrients and filters waste (via the liver)  The umbilical cord Provides circulatory pathway from chorionic villi to embryo. o Body stalk fuses with embryonic portion of the placenta o Wharton’s Jelly protects cord o Remember AVA: (note that what vein/arteries carry is opposite typical)  One Vein- Delivers oxygenated blood and nutrients from placenta  Two Arteries- Delivers deoxygenated blood and waste from fetus to mother  Amniotic fluid contains fetal urine- allows baby to move, provides oral fluid and helps with thermoregulation. Chapter 12: Physiologic and Psychological Changes of Pregnancy Focus Of Antepartum Nursing Care  Regular assessment of the health of the pregnancy  Regular assessment and screening of risk factors for potential complications  Implementation of appropriate interventions based on risk status or actual complications  Inclusion of significant others/family in care and education to promote pregnancy adaptation  Education on health promotion and disease prevention Preconception Health Care  Approximately half of pregnancies are unintended (Old’s, pg. 69)  Preconception counseling involves health screening and identifying any known or potential risks o Smoking, ETOH and street drug use o Medications o Chronic illness o Diet (caffeine) o Environmental hazards Anticipatory Guidance and Teaching  Nutrition o Nutrition- maintains healthy weight and BMI to reduce risk for adverse perinatal outcomes.  Refer under/over weight women to dietary counselor o Low carb diet (<40g/day) is ideal  Prenatal Vitamins o Folic acid supplementation to decrease risk of neural tube defects/ Ca++, Mg+, Vit D to reduce risk of osteoporosis o Iron- Fe supplements are controversial as to whether or not should be routine  Exercise o Best to implement program several months prior to conception in order to maintain routine during pregnancy; weight-bearing exercise decreases risk of osteoporosis  Self-Care o Typically pregnant for 2 weeks before even know so should decrease/stop risk behaviors such as ETOH, tobacco, excessive caffeine, illicit drugs, medications contraindicated in pregnancy both Rx and non-Rx (herbal as well); environmental toxins  Contraception Cessation o Contraception cessation: ideal to have 2-3 normal menstrual cycles prior to conception  Timing of Conception  Modifying Behaviors to Reduce Risks Cultural Factors  Identify beliefs, values, and behaviors: o Rituals tied to important life events  Pregnancy, childbirth, marriage, death  Cultural Assessment o Explore beliefs, values, religious preference  Who will be aloud in room for appointments and birth  Head of baby may be culturally significant  Jehovah witness- no blood transfusions o Expectations of healthcare system  Can provider be male? Signs of Pregnancy  Maternal physiologic adaptations are attributed to the hormones of pregnancy and mechanical pressures associated with the enlarging uterus and other tissue.  Three commonly used signs of pregnancy: o Presumptive o Probable o Positive  Presumptive Signs of Pregnancy- Subjective signs felt by the women. Table 12-1 (p. 231) o Amenorrhea (missed period) o Nausea & vomiting o Breast changes- change in size, tenderness o Fatigue or lack of energy o Quickening o Increased Urinary frequency  Implantation occurs close to bladder and beginning stages of pregnancy the baby is growing mostly in that area, so urinary frequency increases during first trimester. This improves during second trimester  Probable Signs- Objective signs that could have cause other than pregnancy. Table 12-2 (p. 232) o Positive pregnancy test  Pregnancy tests are based on analysis of maternal blood or urine for the detection of Human Chorionic Gonadotropin (hCG). These tests are not considered positive signs of pregnancy because the similarity of hCG and the pituitary-secreted luteinizing hormone (LH) occasionally results in cross-reactions. In addition, certain conditions other than pregnancy can cause elevated levels of hCG. o Enlarged abdomen o Changes in pelvic organs  Uterine enlargement  Goodell sign- softening of the cervix, seen at 6-8 weeks  Chadwick sign- bluish or cyanotic color of cervix and upper vagina, seen at 6-8 wks  Hegar sign- softening of the uterine isthmus, palpable at 6 weeks  Braun von Fernwald sign  Piskacek sign- asymmetrical, softened enlargement of the uterine corner caused by placental development o Uterine Soufflé- auscultated soft, blowing sound heard most clearly in the lower part of the uterus and is synchronous with the pulse of the mother. o Ballottement- the passive fetal movement elicited by pushing up against the cervix with two fingers. o Braxton Hicks contractions o Abdominal Striae- stretch marks o Changes in pigmentation of skin  Chloasma (melasma)  Linea nigra o Nipples/areola o  Positive Signs- the only objective findings of pregnancy that can only be attributed to the fetus: o Detection of fetal heart tones by auscultation, ultrasonography, or Doppler  Should be detectable by 10-12 weeks (should be 110-160) o Detection of fetal movement by examiner o Palpation of fetal body parts using Leopold maneuvers o Visual confirmation of fetus: Ultrasound or X-ray of fetus Mother’s Response to Pregnancy  Ambivalence- more often in unanticipated or unwanted pregnancy  Acceptance  Introversion o This is one reason domestic abuse often increases in relationships at this point  Mood swings  Changes in body image First Trimester  Difficult believing pregnancy, especially if: o Unwanted pregnancy o Unplanned pregnancy o Difficulty getting pregnant  Conflicting feelings o Ambivalence is normal  Emotional swings Second Trimester  Stable time for the pregnancy  Body changes are more evident  Fetus becomes more real  New mom “tries on” the role of motherhood Third Trimester  Body changes are more dramatic  Mother begins to separate herself from the pregnancy, commits to take care of the baby  Minor discomforts become more tiresome Father/Partner response to Pregnancy:  Fathers go through similar phases  Ambivalence is typical  Development stages o Announcement o Adjustment o Focus  Father’s Response to Pregnancy, may be: o Confused by partner’s mood changes o Feel left out of pregnancy o Resent attention given to the woman o Resent changes in their relationship o Need to resolve conflicts about fathering  Couvade o Sympathy symptoms and weight gain o This is relevant for any partner (not just men) Family Response to Pregnancy:  Siblings: o Rivalry o Fear of changing parent relationships  Grandparents: o Closer relationship with expectant couple Increasing support of couple Pregnancy Testing  Human Chorionic Gonadotropin (hCG) is the biological marker that pregnancy tests are based  Production of hCG begins at time of implantation and can be detected in the blood as early as 6 days after implantation. Can be detected in urine 7-8 days after implantation. o These peak around 11 weeks, and then decrease again as placenta matures  Many types of pregnancy testing are available. All rely on the detection of hCG  Types: o Serum o Radioimmunoassay o Enzyme-linked immunosorbent assay (ELISA)  Early detection allows for early initiation of prenatal care  First morning void is most accurate  Interpretation: requires judgment. Certain medications or improper collection can cause false positives o Most common error is performing the test too early in pregnancy Endocrine- Hormones of Pregnancy  hCG o Maintains corpus luteum production of estrogen & progesterone until placenta takes over (approx. 10 weeks) o Causes morning sickness  Estrogen (check this info, may be for progesterone also) o Stimulates contraction? o Myometrial activity o Suppresses secretion of LH/FSH by anterior pituitary o Responsible for fat deposits acquired during pregnancy on abdomen, back and upper thighs. **Purpose is for energy storage o Assists with breast preparation for lactation o Produced by corpus luteum to maintain pregnancy until placenta takes over  Progesterone is the hormone of pregnancy: maintains the endometrium and prevents uterine contractility by relaxing smooth muscle o Without progesterone, pregnancy will be lost o Relaxes peristalsis- causes constipation o Vasodilator, helps allow for increased blood volume  In second trimester this can cause hypotension  Drink more water to improve  Oxytocin is produced by posterior pituitary and stimulates uterine contractions, but high levels of progesterone prevent oxytocin from causing contractions until prog. levels drop near term o Oxytocin levels increase with onset of labor  Serum Prolactin: produced by anterior pituitary rises during 1st trimester and is responsible for initial lactation. o High levels of estrogen & progesterone block this process until after birth o SO after birth, birth control with estrogen & progesterone will inhibit lactation  Human Placental Lactogen (HPL) acts as a growth hormone and antagonist of insulin o Influence on blood sugar o Want more glucose in blood to get to the fetus for growth  Relaxin: softens cervix, inhibits uterine contractions, remodels collagen (affects ALL joints) o Present early in pregnancy and remains until delivery Body System Changes Cervical Changes  Goodell sign: softening of the cervical tip observed around 6th week in a normal cervix. This is brought on by increased vascularity, slight hypertrophy, and hyperplasia.  Chadwick sign: bluish color of the mucosa and cervix; visible at about 6-8 weeks.  Cervix becomes more friable and the squamocolumnar junction may relocate, making obtainment of pap smears difficult.  Leukorrhea: whitish/gray discharge stimulated by estrogen and progesterone. Mucus fills the endocervical canal resulting in a barrier or mucus plug. o Operculum- mucus plug in cervix. May be lost when the cervix begins to dilate, but is not an indicator of imminent labor. Ovaries  Increased blood supply → enlarge until 12-14 weeks  Stop releasing eggs o ↑ estrogen/progesterone block secretion of FSH and LH from anterior pituitary  HGC supports the Corpus luteum, which remains and produces progesterone to maintain the decidua during the first 6-7 weeks until the placenta can perform this function Vaginal Changes  Hormones prepare vaginal canal: o For stretching during labor by loosening connective tissue o By thickening vaginal mucosa and vaginal vault to lengthen.  Secretions become more acidic (3.5-6.0) o Inhibits bacterial growth o Yeast overgrowth a risk during pregnancy  Can result in preterm labor  This is why urine is checked at visits Uterus  Hegar sign: around 6 weeks of gestation, softening and compressibility of the lower uterine segment occur, causing uterine anteflexion during first three months. This causes increase in urinary frequency due to the pressure on the bladder. (not on test)  Uterine growth in the first trimester is stimulated by high levels of estrogen and progesterone o Early enlargement results from increased vascularity, hypertrophy and the development of the decidua (uterine lining that forms the maternal part of the placenta).  Uterus grows to 20-22x normal size during pregnancy o Uterus is palpable above the symphysis pubis between 12 & 14 weeks o Fundus (top) of uterus reaches the umbilicus at 20 -22 weeks o McDonald’s Rule-the fundus to symphysis distance in centimeters is equal to the week of gestation between the 20th to 31st week of pregnancy o Fundus reaches the Xiphoid process near term  Uteroplacental blood flow: Placental perfusion is dependent on maternal blood flow to the uterus. o Mother’s blood flow may increase 50-60% during pregnancy  Rate of blood flow to uterus averages 500ml/min. o Oxygen consumption increases to meet fetal blood oxygenation needs o Factors that cause decreased blood flow:  Low maternal arterial pressure (hypotension, dehydration, shock)  Maternal supine position (pressure on vena cava)  Contractions  Quickening: “flutter feeling” in abdomen  Braxton Hicks: around 4 months, uterine contractions can be felt. They are irregular and painless. o Caused by hormone fluxuations o Purpose is to facilitate blood flow through the placenta thereby delivering 02 to fetus o Also referred to as false labor  Ballottement: passive movement of the unengaged fetus, identified between 6 -18 weeks. Until the baby is fully engaged in the pelvis before birth, there is usually some ballottement. May be elicited by pushing up against the cervix with two fingers.  Lightening: when the baby “drops”, between 38-40 weeks, fundal height drops as the fetus descends into the pelvis. Mother will be able to breath a little easier, but will have to urinate more frequently Breasts  Fullness and sensitivity begin in early weeks of pregnancy due to increased levels of estrogen and progesterone.  Pigmentation increases due to increase in melanin  Montgomery tubercles: sebacious glands visible around nipples.  Nipples become more erect  Mammary glands fully functioning by mid-pregnancy but lactation inhibited until drop in estrogen after birth o Colostrum may be evident during pregnancy and last for first few days after birth Cardiovascular System  Blood volume increases by 40-50% (or 1500ml) above pre-pregnant levels  Physiologic anemia of pregnancy (pseudoanemia) o Disproportionate shifts in RBC and plasma occur o Plasma increases 50%, RBCs increases only 18%  Increased volume is a protective measure to meet volume demands during pregnancy and a reserve for labor  This also thins the blood  Normal hematocrit (Hct) for non-pregnant women is 38% to 45%  Pseudoanemia: decrease to about 34% during late single pregnancy and to 30% during late multifetal pregnancy.  Falsely low hematocrit and hemoglobin due to dilution  During pregnancy, true anemia is defined as:  hemoglobin (Hb) < 10 g/dL and hematocrit (Hct) < 30%  Cardiac output increases from 30% -50% by 32nd week.  Slight cardiac hypertrophy occurs due to increased blood volume and cardiac output  Alterations in heart sounds heard during pregnancy are transient and resolve after birth.  Alterations in rhythm may be noted. Acceptable in normal healthy heart. Needs monitoring in women with preexisting conditions or heart disease  Increased coagulation to protect against bleeding out from labor. o Increases risk for postpartum thrombosis o Also at risk for DVTs during pregnancy, so avoid prolonged sitting  Blood Pressure: o 1st trimester blood pressure should remain the same as pre-pregnancy o 2nd trimester there is a decrease in both systolic and diastolic (5-10 mm Hg) due to peripheral vasodilation from hormonal changes (progesterone) o 3rd trimester BP should return to normal baseline levels o Supine hypotensive syndrome (aka vena cava syndrome):  Weight of the uterus compresses the vena cava, reducing the amount of blood returned to her heart, resulting in:  Faintness  Lightheadedness  Agitation  Dizziness  Treatment:  DO NOT LIE FLAT ON BACK! Respiratory System  Maternal oxygen requirements increase in response to accelerated metabolic demands  Increased metabolic rate increases oxygen consumption and increased respirations as a means to eliminate excess carbon dioxide.  Increased estrogen and relaxin levels allow for relaxation of rib cage for expansion o ** relaxin affects ALL joints and ligaments Renal System  Hormones affect renal structure during pregnancy  12th week ureters dilate and elongate, larger amounts of urine are held here  Consequences: o Inaccurate clearance test due to lag time between urine formation and reaching bladder o Stagnate urine is a breeding ground for organisms o Urinary frequency will decrease (for a while)  Bladder frequency: compression by uterus o Occurs during 1st & 3rd trimester o Bladder tone decreases which increases holding capacity Gastrointestinal  Appetite: o Early on morning sickness may depress appetite. Certain smells or foods may cause an adverse response.  HcG causes poor carbohydrate metabolism in during first trimester, so eating more protein and smaller carb meals will help. As HcG levels decrease, morning sickness often improves.  Lack of vitamin B6 may also contribute  **Ginger helpful o 2nd trimester appetite increases due to increased metabolic demands. May develop cravings, or a change in dietary intake  Ptyalism: excessive salivation  Pica: nonfood cravings may develop, typically due to iron deficiency.  Most common cravings are dirt, chalk  GI Tract o Hiatal hernia: herniation of upper portion of stomach due to displacement of stomach  Most common in multiparous women o High levels of progesterone increase risk for:  Pyrosis: heartburn  Constipation: due to loss of muscle tone and decreased perstalsis o Higher risk for gallstones due to:  Increased levels of progesterone and decreased muscle tone  Increased emptying time and thickening of bile Musculoskeletal System  Postural Changes due to: o Weight gain o Abdominal distention weakens muscle tone o Relaxin makes all joints more loose  =Lordosis: sway back  Diastasis Recti: separation of abdominal muscles (usually caused by progesterone) Integumentary System (skin)  Alterations in hormone balance and stretching cause changes in integumentary during pregnancy  Hyperpigmentation: stimulated by anterior pituitary- responsible for darkening of nipples, areolae and chloasma- facial melasma.  Linea nigra: pigmented line from symphysis pubis to top of fundus  Striae gravidarum: (stretch marks)caused by action of adrenocorticosteriods  PUPPP (Pruritic urticarial papules and plaques of pregnancy) o Dermatitis development during pregnancy o Benign – but uncomfortable – treated with antihistamines, oral steroids Metabolism  Maternal reserves: o Extra storage of fat, water and protein  Recommended total weight gain during pregnancy: o Normal weight gain: 25-35 lbs o Underweight: 28-40lbs o Overweight: 15-25lbs o Obese: 11-20lbs  Weight Distribution throughout pregnancy: o 2 to 4.4 lbs during 1st trimester o About 1lb per week during 2nd & 3rd trimesters o First trimester 2-4.4 lb, second trimester 12-14 lb, third trimester 8-12 lb Pregnancy Assessment Exercises (p 230-233) Match the assessment date in Column I with the answers in Column II: A: Presumptive Signs (subjective) B: Probable Sign (objective) C: Positive Sign (objective) 1 B Striae gravidarum 2 A Breast tenderness 3 B Chadwick’s Sign- bluish or cyanotic color of cervix and upper vagina 4 B Enlarged abdomen 5 C Fetal movement noted by examiner 6 A Fatigue or lack of energy 7 B Chloasma or linea nigra (changes in skin pigmentation) 8 A Quickening- fluttering sensation in abdomen 9 B Elevated Fundus 10 A Nausea and vomiting 11 B Uterine soufflé 12 A Urinary frequency 13 B Braxton Hicks contractions 14 A Amenorrhea 15 C Fetal heart tones 16 B Positive pregnancy test 17 B Goodell’s sign- softening of the cervix 18 C Ultrasound view of the fetus 19 C X-ray of fetus (not a typical test for viable pregnancy)